Effects of a web-based patient activation intervention to overcome clinical inertia on blood pressure control: cluster randomized controlled trial.

BACKGROUND: Only approximately half of patients with hypertension have their blood pressure controlled, due in large part to the tendency of primary care providers (PCPs) not to intensify treatment when blood pressure values are elevated. OBJECTIVE: This study tested the effect of an intervention designed to help patients ask questions at the point of care to encourage PCPs to appropriately intensify blood pressure treatment. METHODS: PCPs and their patients with hypertension (N=500) were recruited by letter and randomized into 2 study groups: (1) intervention condition in which patients used a fully automated website each month to receive tailored messages suggesting questions to ask their PCP to improve blood pressure control, and (2) control condition in which a similar tool suggested questions to ask about preventive services (eg, cancer screening). The Web-based tool was designed to be used during each of the 12 study months and before scheduled visits with PCPs. The primary outcome was the percentage of patients in both conditions with controlled blood pressure. RESULTS: Of 500 enrolled patients (intervention condition: n=282; control condition: n=218), 418 (83.6%) completed the 12-month follow-up visit. At baseline, 289 (61.5%) of participants had controlled blood pressure. Most (411/500, 82.2%) participants used the intervention during at least 6 of 12 months and 222 (62.5%) reported asking questions directly from the Web-based tool. There were no group differences in asking about medication intensification and there were no differences in blood pressure control after 12 months between the intervention condition (201/282, 71.3%) and control condition (143/218, 65.6%; P=.27) groups. More intervention condition participants discussed having a creatinine test (92, 52.6% vs 49, 35.5%; P=.02) and urine protein test (81, 44.8% vs 21, 14.6%; P<.001), but no group differences were observed in the rate of testing. The control condition participants reported more frequent discussions about tetanus and pneumonia vaccines and reported more tetanus (30, 13.8% vs 15, 5.3%; P=.02) and pneumonia (25, 11.5% vs 16, 5.7%; P=.02) vaccinations after 12 months. CONCLUSIONS: The use of an interactive website designed to overcome clinical inertia for hypertension care did not lead to improvements in blood pressure control. Participant adherence to the intervention was high. The control intervention led to positive changes in the use of preventive services (eg, tetanus immunization) and the intervention condition led to more discussions of hypertension-relevant tests (eg, serum creatinine and urine protein). By providing patients with individually tailored questions to ask during PCP visits, this study demonstrated that participants were likely to discuss the questions with PCPs. These discussions did not, however, lead to improvements in blood pressure control. TRIAL REGISTRATION: ClinicalTrials.gov NCT00377208; http://clinicaltrials.gov/ct2/show/NCT00377208 (Archived by WebCite at http://www.webcitation.org/6IqWiPLon).

Implementing effective care management in the patient-centered medical home.

BACKGROUND: There is growing evidence that practice-based care management can improve clinical quality and reduce costly healthcare utilization. OBJECTIVES: To explore how a disparate group of patient-centered medical homes (PCMHs) embedded care management in their team care environment to identify best practices. STUDY DESIGN: A positive deviance approach was used to contrast care management implementation in practices having the greatest and least improvement on clinical measures of diabetes, the initial target disease for a multipayer-supported statewide initiative involving 25 National Committee on Quality Assurance-recognized PCMH practices participating in a regional learning collaborative. METHODS: Practices were ranked according to their average absolute percentage point increase from baseline to 18 months on 3 diabetes quality measures. Semistructured interviews were conducted with 136 individuals in 21 of the 25 practices. Interview data were analyzed using grounded theory with NVivo 9.0 software. To develop hypotheses related to care management best practices, we compared and contrasted emerging themes across clinical performance tertiles. RESULTS: Practices with the greatest diabetes improvement described (1) more patient-centered care manager duties, (2) better use of the electronic medical record (EMR) for messaging and patient tracking, and (3) stronger integration of the care manager into the care team compared with practices with the least diabetes improvement. CONCLUSIONS: PCMHs may want to ensure that care managers are available to meet with patients during visits, support patient self-management, fully leverage the EMR for team messaging and patient tracking, and ensure integration into the care team with office huddles and ongoing communication.

Nurse case management improves blood pressure, emotional distress and diabetes complication screening.

We studied the impact of nurse case management (NCM) on blood pressure (BP), hemoglobin A1C, lipids, and diabetes complication screening. A 1-year randomized-controlled trial was conducted in two primary care clinics of the Penn State Hershey Medical Center. Diabetes patients were randomized to control group (CG) (n=182) who received usual care by their primary care provider and intervention group (IG) (n=150) who received additional NCM care, including self-management education, and implementation of diabetes guidelines. Primary outcomes included BP, A1C, lipid, process measures, and secondary outcome was diabetes-related emotional distress as assessed by Problem Areas in Diabetes (PAID). BP significantly decreased from 137/77 to 129/72 in IG as compared to an increase from 136/77 to 138/79 in CG after 1 year. PAID scores improved significantly in IG (from 23 to 10) due to reduced emotional stress. A1C (7.4) and LDL (105) were unaffected. Complications screening significantly improved in IG compared to CG: opthalmologic exam 26 to 68%, foot exam 47 to 64%, and nephropathy screening 34 to 72%. NCM improved BP, diabetes-related emotional distress, and process measures in primary care. Unchanged A1C and lipids might be due to a threshold effect. Intervention based upon initial risk assessment may prove more cost-effective.

Initial evaluation of the patient with suspected dementia.

Dementia is a common disorder among older persons, and projections indicate that the number of patients with dementia in the United States will continue to grow. Alzheimer's disease and vascular dementia account for the majority of cases of dementia. After a thorough history and physical examination, including a discussion with other family members, a baseline measurement of cognitive function should be obtained. The Mini-Mental State Examination is the most commonly used instrument to document cognitive impairment. Initial laboratory evaluation includes tests for thyroid-stimulating hormone and vitamin B12 levels. Structural neuroimaging with noncontrast computed tomography or magnetic resonance imaging also is recommended. Other testing should be guided by the history and physical examination. Neuropsychologic testing can help determine the extent of cognitive impairment, but it is not recommended on a routine basis. Neuropsychologic testing may be most helpful in situations where screening tests are normal or equivocal, but there remains a high level of concern that the person may be cognitively impaired.

Appropriateness of quality indicators for older patients with advanced dementia and poor prognosis.

OBJECTIVES: To evaluate the applicability of process-of-care quality indicators (QIs) to vulnerable elders and to measure the effect of excluding indicators based on patients' preferences and for advanced dementia and poor prognosis. DESIGN: The Assessing Care of Vulnerable Elders (ACOVE) project employed 203 QIs for care of 22 conditions (including six geriatric syndromes and 11 age-associated diseases) for community-based persons aged 65 and older at increased risk of functional decline or death. Relevant QIs were excluded for persons deciding against hospitalization or surgery. A 12-member clinical committee (CC) of geriatric experts rated whether each QI should be applied in scoring quality of care for persons with advanced dementia (AdvDem) or poor prognosis (PoorProg). Using content analysis, CC ratings were formulated into a model of QI exclusion. Quality scores with and without excluded QIs were compared. SETTING: Enrollees in two senior managed care plans, one in the northeast United States and the other in the southwest. PARTICIPANTS: CC members evaluated applicability of QIs. QIs were applied to 372 vulnerable elders in two senior managed care plans. MEASUREMENTS: Frequency and type of QIs excluded and the effect of excluding QIs on quality of care scores. RESULTS: Of the 203 QIs, a patient's preference against hospitalization or surgery excluded 10 and eight QIs, respectively. The CC voted to exclude 81.5 QIs (40%) for patients with AdvDem and 70 QIs (34%) for patients with PoorProg. Content analysis of the CC votes revealed that QIs aimed at care coordination, safety or prevention of decline, or short-term clinical improvement or prevention with nonburdensome interventions were usually voted for inclusion (90% and 98% included for AdvDem and PoorProg, respectively), but QIs directed at long-term benefit or requiring interventions of moderate to heavy burden were usually excluded (16% and 19% included, respectively). About half of QIs aimed at age-associated diseases were voted for exclusion, whereas fewer than one-quarter of QIs for geriatric syndromes were excluded. Thirty-nine patients (10%) in our field trial held preferences or had clinical conditions that would have excluded 68 QIs. This accounted for 5% of all QIs triggered by these 39 patients and 0.6% of QIs overall. The quality score without exclusion was 0.57 and with exclusion was 0.58 (P =.89). CONCLUSION: Caution is required in applying QIs to vulnerable elders. QIs for geriatric syndromes are more likely to be applicable to these individuals than are QIs for age-associated diseases. The objectives of care, intervention burdens, and interval before anticipated benefit affect QI applicability. At least for patients with AdvDem and PoorProg, identification of applicable or inapplicable QIs is feasible. In a community-based sample of vulnerable elders, few QIs are excluded.

Integrating Web-based computer cases into a required clerkship: development and evaluation.

PURPOSE: To evaluate a five-year experience (1995-2000) developing and integrating computer cases into a required clerkship. METHOD: In Study 1, 54 volunteer students were randomly assigned to study articles, a paper case, or a computer case on low back pain/kidney stones. Students were given an exam immediately after the exercise and one week later. In Study 2, 325 clerkship students were asked to select and complete two computer cases or to prepare assignments on unrelated topics. Among the cases offered were two test cases on low back pain/kidney stones and pneumonia. Questions specific to the computer test cases (CC) and other noncomputer cases (NCC) were in the final exam. Exam scores related to CC questions and NCC questions were compared between the groups of students who did and did not complete the computer cases. Students also rated the computer cases on a questionnaire. RESULTS: In Study 1, reading articles required the most time and received the most negative comments. The students who completed the computer case scored the best on the exam one week later. In Study 2, the students who completed the two computer cases scored significantly higher on the CC questions than did students who studied only one or none of the computer cases (p <.001). There was no difference among groups for the NCC scores (p =.76). Students rated the computer cases with a mean of 6 on a seven-point scale (7 = strongly agree). CONCLUSION: Computer cases are effective learning tools, are well-received by students, and can be successfully integrated into existing clerkships.